• Chiara Mega, Irene Cavalli, Vito Marco Ranieri, and Tommaso Tonetti.
• Alma Mater Studiorum - Università di Bologna, Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, IRCCS Policlinico di Sant'Orsola, Bologna, Italy.
• Curr Opin Crit Care. 2022 Feb 1; 28 (1): 515651-56.

Purpose Of ReviewTo review current evidence on the pathophysiology of COVID-19-related acute respiratory distress syndrome (ARDS) and on the implementation of lung protective ventilation.Recent FindingsAlthough multiple observations and physiological studies seem to show a different pathophysiological behaviour in COVID-19-ARDS compared with 'classical' ARDS, numerous studies on thousands of patients do not confirm these findings and COVID-19-ARDS indeed shares similar characteristics and interindividual heterogeneity with ARDS from other causes. Although still scarce, present evidence on the application of lung protective ventilation in COVID-19-ARDS shows that it is indeed consistently applied in ICUs worldwide with a possible signal towards better survival at least in one study. The levels of positive end-expiratory pressure (PEEP) usually applied in these patients are higher than in 'classical' ARDS, proposing once again the issue of PEEP personalization in hypoxemic patients. In the absence of robust evidence, careful evaluation of the patient is needed, and empiric settings should be oriented towards lower levels of PEEP.SummaryAccording to the present evidence, a lung protective strategy based on low tidal volume and plateau pressures is indicated in COVID-19-ARDS as in ARDS from other causes; however, there are still uncertainties on the appropriate levels of PEEP.Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

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